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Herman & Wallace Blog

Women and Sex – After Cancer (Part Two)

Today we present Part II of Michelle Lyons' discussion on sex after gynecologic cancer. Michelle will be teaching a course on this topic in White Plains in August!

In Part One of this blog, I looked at the sexual health issues women face after gynecologic cancer. In Part Two, I want to explore different treatment options that we as pelvic rehab specialists can employ to help address the many implications of cancer and cancer treatment

Treatment for gynecologic cancers, including vulvar, vaginal, cervical, endometrial and ovarian cancers, may include surgery, radiation therapy, chemotherapy, and/or hormonal therapy. We know that any of these approaches can have an adverse effect on the pelvic floor, as well as systemic effects on a woman’s body. Issues can include pain, fibrosis, scar tissue adhesions, diminished flexibility, fatigue and feeling fatigued and unwell. The effects on body image should not be under-estimated either. In their paper ‘Sexual functioning among breast cancer, gynecologic cancer, and healthy women’, Anderson & Jochimsen explore how ‘…body-image disruption may be a prevalent problem for gynecologic cancer patients…more so than for breast cancer patients’. The judicious use of manual therapy and local and global exercise prescription may be excellent pathways for a women to re-integrate with her body.

Many women will have to learn to care for a new colostomy or how to catheterize a continent urostomy. A woman who has had a vulvectomy will need sensitive counselling to understand that she can still respond sexually. Patients who have had a vaginectomy with reconstruction as part of a pelvic exenteration will need extensive rehab to help them achieve successful sexual functioning. We as pelvic rehab practitioners are in a uniquely privileged position – not only can we ask the questions and discuss the options but we are licensed to be ‘hands on’ professionals, using our core skills of manual therapy, bespoke exercise advice and educating our patients about a range of issues from the correct usage of lubricants, dilators, sexual ergonomics and brain/pain science. I am in the habit of describing pelvic rehab as the best specialty in physical therapy but I think this is especially true when it comes to the junction of oncology and pelvic health. This is where we can integrate our knowledge of neuro-science, orthopaedics, the lymphatic system and pelvic health to deal with the effects of pelvic cancers and their treatment.

In Farmer et al’s 2014 paper, ‘Pain Reduces Sexual Motivation in Female But Not Male Mice’ , the authors found that ‘Pain from inflammation greatly reduced sexual motivation in female mice in heat -- but had no such effect on male mice’. Unfortunately ongoing pelvic pain is a common sequela of treatment for gynecologic cancers – reasons ranging from post-operative adhesions, post-radiation fibrosis or vaginal stenosis or genital lymphedema. It is also worth bearing in mind the ‘rare but real’ scenario of pudendal neuralgia following pelvic radiation, as discussed by Elahi in his 2013 article ‘Pudendal entrapment neuropathy: a rare complication of pelvic radiation therapy.’

The good news is that we have much to offer. Yang in 2012 (‘Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: A randomized controlled trial’) showed that pelvic rehab improved overall pelvic floor function, sexual functioning and QoL measures for gynecological cancer patients. Yang’s pelvic rehab group (administered by an experience physiotherapist) displayed statistically significant differences in physical function, pain, sexual worry, sexual activity, and sexual/vaginal function. Gynecological cancer and treatment procedures are potentially a fourfold assault: on sexual health, body image, sexual functioning, and fertility. Sexual morbidity is an undertreated problem in gynecological cancer survivorship that is known to occur early and to persist beyond the period of recovery (Reis et al 2010). We have a good and growing body of evidence that pelvic rehab, delivered by skilled therapists, has the potential to address each of these issues. And perhaps, most encouraging, here is Yang’s conclusion: ‘…‘Pelvic Floor Rehab is effective even in gynecological cancer survivors who need it most.’ (Yang 2012)

Interested in learning more about the role of pelvic rehab in gynecologic cancer survivorship? Join me in White Plains in August!

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Pelvic Dysfunction in Female Cyclists

Blog by Holly Tanner

A US study published in the International Society for Sexual Medicine last year reports on the available evidence linking cycling to female sexual dysfunction. In the article, some of the study results are summarized in the left column of the chart below. On the right side of the column, we can consider ideas about how to potentially address these issues.

 

 


 

Examples of Research Cited
Ideas for Addressing Potential for Harm
dropped handlebar position increases pressure on the perineum and can decrease genital sensation encourage cyclists to take breaks from dropped position, either by standing up or by moving out of drops temporarily
chronic trauma can cause clitoral injury encourage cyclists to wear appropriately padded clothing, to apply cooling to decrease inflammation, and to use quality shocks or move out of the saddle when going over rough roads/terrain when able
saddle loading differs between men and women women should consider specific fit for bike saddles
women have greater anterior pelvic tilt motion is pelvic motion on bike demonstrating adequate stability of pelvis or is there a lot of extra motion and rocking occurring?
lymphatics can be harmed from frequent infections and from groin compression patients should be instructed in positions of relief from compression and in self-lymphatic drainage
pressure in the perineal area is affected by saddle design, shape female cyclists with concerns about perineal health should work with a therapist or bike expert who is knowledgeable about a variety of products and fit issues
unilateral vulvar enlargement can occur from biomechanics factors therapists should evaluate vulvar area for size, swelling, and evidence of imbalances in the tissues from side to side, and evaluate bike fit and mechanics, encouraging women to create more symmetry of limb use
genital sensation is frequently affected in cyclists, indicating dysfunction in pudendal nerve therapists should evaluate female cyclists for sensory or motor loss, establishing a baseline for re-evaluation

Because women tend to be more comfortable in an upright position, the authors recommend that a recreational (more upright) versus a competitive (more aerodynamic and forward leaning) position may be helpful for women when appropriate. Although saddles with nose cut-outs and other adaptations such as gel padding in seats are discussed in the article, the authors caution against making any distinct recommendations due to the paucity of literature that is available. The paper concludes that more research is needed, and particularly for considering the varied populations of riders ranging from recreational to racing.

 

Within a pelvic rehabilitation setting, applying all orthopedic and specific pelvic rehabilitation skills is necessary for women cyclists who present with pelvic dysfunction. Because injury to the perineal area including the pudendal nerve can have negative impact on function such as bowel, bladder, or sexual health, skills in helping a patient heal from compressive or traumatic cycling injuries is very valuable. To learn more about pudendal nerve health and dysfunction, the Institute offers a 2-day course titled Pudendal Neuralgia Assessment, Treatment and Differentials: A Brain/Pain Approach. This course is offered next in Salt Lake City in April, so sign up soon!

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Overactive Bladder and the Role of the Pelvic Floor

Relaxation Training for UI

How does pelvic floor muscle function differ in women with symptoms of overactive bladder compared to symptomatic women? A study completed by Knight and colleagues included determining if pelvic floor muscle surface electromyography (EMG) and pelvic floor muscle (PFM) performance were different among these groups. Scores regarding anxiety, life stress, and quality of life were assessed. Symptoms of overactive bladder can include urinary urgency, frequency, nocturia, and leakage of urine. Subjects in this study had "dry" overactive bladder, meaning that the patients did not experience leakage associated with the urgency.

28 women with urinary urges and frequency were age-matched to 28 asymptomatic controls. Participants completed the Beck Anxiety Inventory, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Recent Life Changes Questionnaire. Surface EMG was utilized to assess pelvic floor muscle function. Results of the study included that women with urinary urgency and frequency had significantly more anxiety than women in the control group. Surface EMG measures (pathway vaginal sensor was used with self-placement) were not significantly different for ability to contract or relax the PFM. Scores on the PFIQ and the RLCQ were significantly higher for women with overactive bladder. The authors conclude that, although a causative relationship could not be made between overactive bladder and anxiety, there exists a relationship between the two conditions.

Another interesting study which compared interventions of yoga versus mindfulness for women who have symptoms of urinary urge incontinence found that mindfulness-based stress reduction was effective for reducing urinary incontinence episodes whereas yoga was not. This study followed a pilot directed by the same primary investigator which showed similar positives results of mindfulness training on urinary urge incontinence.

What are the clinical questions we may draw from these research reports? Does anxiety cause urinary urgency and frequency, or does urinary urgency and frequency cause anxiety? We all have felt the intense stress of having to empty our bladders and not knowing where the nearest restroom (or freeway exit) is. We also know how the bladder and bowels are affected by stress- how many times did you visit the port-a-potty before that last 5K run? As is the case with many conditions with which our patients present, we may not know if one started the other, and most likely, the combination of issues resulted in dysfunction. Regardless, in our pelvic rehabilitation practices we have the tools to help patients learn about their anatomy, physiology, power in healing, and skills to affect urinary urgency and frequency.

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The Role of the Pelvic Therapist in Treating Endometriosis

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy. She will be presenting this course this February!

 

Michelle Lyons

Endometriosis is a common gynaecological disorder, affecting up to 15% of women of reproductive age. Because endometriosis can only be diagnosed surgically, and also because some women with the disease experience relatively minor discomfort or symptoms, there is some controversy regarding the estimates of prevalence, with some authorities stating that as many as one and three women may have endometriosis (Eskenazi & Warner 1997)

 

There is a wide spectrum of symptoms of endometriosis, with little or no correlation between the acuteness of the disease and the severity of the symptoms (Oliver & Overton 2014). The most commonly reported symptoms are severe dysmenorrhoea and pelvic pain between periods. Dyspareunia, dyschezia and dysuria are also commonly seen. These pain symptoms can be severe and have been reported to lead to work absences by 82% of women, with an estimated cost in Europe of €30 billion per year (EST 2005). Secondary musculoskeletal impairments caused by may include: lumbar, sacroiliac, abdominal and pelvic floor pain, muscle spasms/ myofascial trigger points, connective tissue dysfunction, urinary urgency, scar tissue adhesion and sexual dysfunction (Troyer 2007) – all of which may be responsive to skilled pelvic rehab intervention.

 

Endometriosis can lead to inflammation, scar tissue and adhesion formation and myofascial dysfunction throughout the abdominal and pelvic regions. This can set up a painful cycle in the pelvic floor muscles secondary to the decrease in pelvic and abdominal organ/muscle/fascia mobility which can subsequently lead to decreased circulation, tight muscles, myofascial trigger points, connective tissue dysfunction and pain and possible neural irritation.

 

Abdominal trigger points and pain can be commonly seen after laparascopic surgery for diagnosis or treatment. We know that fascially, the abdominal muscles are closely connected with the pelvic floor muscles and dysfunction in one group may trigger dysfunction in the other, as well as causing associated stability, postural and dynamic stability issues.

 

The pain created by muscle tension and dysfunction, may lead to further pain and increasing central sensitisation and further disability. Unfortunately for the endometriosis patient, as well as dealing with the problems already associated with endometriosis, she may also develop a spectrum of secondary musculo-skeletal problems, including pelvic floor dysfunction – and for some patients this may actually be responsible for the majority of their pain (Troyer 2007).

 

The skilled pelvic rehab therapist has much to offer this under-served patient population in terms of reducing pain and dysfunction, educating regarding self-care and exercise and helping to restore quality of life. Interested in learning more? Join me for my new course: ‘Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy’ in San Diego this February or Chicago in June.

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The Role of the Pelvic Therapist in Treating Endometriosis

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy. She will be presenting this course this February!

Michelle Lyons

Endometriosis is a common gynaecological disorder, affecting up to 15% of women of reproductive age. Because endometriosis can only be diagnosed surgically, and also because some women with the disease experience relatively minor discomfort or symptoms, there is some controversy regarding the estimates of prevalence, with some authorities stating that as many as one and three women may have endometriosis (Eskenazi & Warner 1997)

There is a wide spectrum of symptoms of endometriosis, with little or no correlation between the acuteness of the disease and the severity of the symptoms (Oliver & Overton 2014). The most commonly reported symptoms are severe dysmenorrhoea and pelvic pain between periods. Dyspareunia, dyschezia and dysuria are also commonly seen. These pain symptoms can be severe and have been reported to lead to work absences by 82% of women, with an estimated cost in Europe of €30 billion per year (EST 2005). Secondary musculoskeletal impairments caused by may include: lumbar, sacroiliac, abdominal and pelvic floor pain, muscle spasms/ myofascial trigger points, connective tissue dysfunction, urinary urgency, scar tissue adhesion and sexual dysfunction (Troyer 2007) – all of which may be responsive to skilled pelvic rehab intervention.

Endometriosis can lead to inflammation, scar tissue and adhesion formation and myofascial dysfunction throughout the abdominal and pelvic regions. This can set up a painful cycle in the pelvic floor muscles secondary to the decrease in pelvic and abdominal organ/muscle/fascia mobility which can subsequently lead to decreased circulation, tight muscles, myofascial trigger points, connective tissue dysfunction and pain and possible neural irritation.

Abdominal trigger points and pain can be commonly seen after laparascopic surgery for diagnosis or treatment. We know that fascially, the abdominal muscles are closely connected with the pelvic floor muscles and dysfunction in one group may trigger dysfunction in the other, as well as causing associated stability, postural and dynamic stability issues.

The pain created by muscle tension and dysfunction, may lead to further pain and increasing central sensitisation and further disability. Unfortunately for the endometriosis patient, as well as dealing with the problems already associated with endometriosis, she may also develop a spectrum of secondary musculo-skeletal problems, including pelvic floor dysfunction – and for some patients this may actually be responsible for the majority of their pain (Troyer 2007).

The skilled pelvic rehab therapist has much to offer this under-served patient population in terms of reducing pain and dysfunction, educating regarding self-care and exercise and helping to restore quality of life. Interested in learning more? Join me for my new course: ‘Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy’ in San Diego this February or Chicago in June.

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The Pudendal Nerve and Order of Movement

Pudendal nerve dysfunction, when severe, is truly one of the most difficult conditions treated by pelvic rehabilitation providers. While peripheral nerve dysfunction anywhere in the body can be challenging to treat, access to the nerve along its many potential sites of irritation is limited when compared to other peripheral nerves. Many research studies have been completed that investigate how structures like the median nerve move in the body, and to what extent the nerve movement changes in cases of dysfunction, yet we still have very little to work with regarding the pudendal nerve. Little, that is, except anatomical knowledge, nerve and tissue mapping and palpation skills, expert listening and evaluation skills, and an abundance of existing and emerging methodology directed to treatment of chronic pain conditions.

The Neuro Orthopaedic Institute (also known as the NOI group)has led the physiotherapy world in seeking and sharing knowledge about the evaluation and treatment of conditions involving the nervous system. In a prior posting within the "noinotes" available as a newsletter from the NOI group, the following is stated: "…for the best clinical exposure of a peripheral nerve problem, take up the part that you think holds the problem first and then progressively add tension to the nerve via the limbs." Let's say, for example, that you gently tension the pudendal nerve by completing an inferior compression of the right levator ani muscle group (towards the lateral portion of the muscle belly versus at the midline). At this point, what limb movement should be performed to increase tension to the nerve? Does a straight leg raise tension the nerve, or hip rotation, hip adduction? What evidence do we have that this nerve tension increases in terms of elongation of the peripheral nerve, and by what connective tissue attachments is this tension proposed to occur? And for using order of movement in the clinic, do we start with a pelvic muscle bearing down or contraction, then add trunk or limb movements?

The "Ordering nerves" post describes listening "…to the patient about the sequence of movements which aggravate them.." so that with clinical reasoning, for evaluation or treatment, the nerve symptoms can be reproduced to an appropriate extent. For example, if a pelvic muscle contraction significantly aggravates a patient's nerve-like symptoms, why should a patient be instructed, or allowed even, to do Kegel muscle exercises to a degree that causes significant pain? If a patient has low grade, annoying symptoms that are only reproduced with posterior pelvic floor stretch combined with an anterior pelvic tilt and passive straight leg raise with internal rotation of the hip, then that position should be incorporated into a clinical and a home program if able.

Just because we don't yet know how patients with true pudendal nerve dysfunction present clinically in terms of nerve gliding ability, and what movements typically engage particular portions of the nerve (such as the proximal portion in the posterior pelvis, the portion that lives along the obturator internus, the portion housed by the Alcock's canal, or even the longest portion of the nerve that extends to the genitals), that does not mean we should default to a one-size-fits-all pelvic muscle strengthening or stretching approach. Each patient must be met with curiosity, and with keen knowledge of anatomy, nerve evaluation principles, and pain-brain centered skills so that an individual approach is designed. As is concluded in this post from the NOI group, we must "Keep playing with order of movement."

If you would love to fill up your toolbox with concepts and techniques for treating pudendal nerve dysfunction, sign up quickly for the last chance this year to take Pudendal Neuralgia and Treatment in San Diego this August.

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Scientists Discover Protein for Diagnosing Crohn's Disease

Scientists at the National University of Ireland in Maynooth reported the detection of a protein, Pellino3 that may stop Crohn's disease from developing. The Irish Times article, University breakthrough in fight against Crohn's disease, described the benefit as diagnostic: [Researchers] will now use the protein as a basis for new diagnostic for Crohn's and as a target in designing drugs to treat the illness.

Researchers noticed that levels of Pellino3 are dramatically reduced in Crohn's disease patients. Prof. Paul Moynagh, who led the researchers, believes that identifying Pellino3s role in Crohn's disease may lead to better treatments for other inflammatory bowel diseases.

In the United States, more than a half-million people suffer from Crohn's disease and more than a million suffer from some type of inflammatory bowel disease. Symptoms often include abdominal pain and diarrhea. These symptoms are often debilitating and even life-threatening. There is neither a known cause nor cure for Crohn's disease.

Therapy has been known as one of the few treatments that can reduce symptoms and even lead to remission.

Hopefully, this discovery will lead to further advancements in treating Crohn's disease: The findings by Prof Moynagh and his team have the potential to impact positively on many lives.

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Pelvic Floor Muscles: to Strengthen or Not to Strengthen?

Pelvic Floor Muscles: To Strengthen or Not to Strengthen? 

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a few images. 

 

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles. 

 

Rhonda Kotarinos and Mary Pat Fitzgerald did the world of pelvic rehab an immense good with their promotion of the concept of the "short pelvic floor."  If a patient presents with pelvic muscle tension, shortening of the muscle, and poor ability to generate a contraction, a relaxation phase, or a bearing down of the pelvic muscles, how in the world will trying to tighten those overactive muscles bring progress? This concept is further described in a 2012 article from the Mayo Clinic by Dr. Faubion and colleagues. The article explains the cluster of symptoms commonly seen with non-relaxing pelvic floor muscles including pain and dysfunction in bowel, bladder, and sexual function. Medical providers and rehab clinicians should look for this cluster of symptoms and combine this knowledge with a pelvic muscle assessment to decide if pelvic muscle strengthening is warranted. 

 

If this has not been a part of your current practice, please consider ruling out a shortened or non-relaxing pelvic floor prior to suggesting any "Kegels" or pelvic muscle strengthening. If you are well aware of this issue, then it is our responsibility and opportunity to educate the public and the medical community to STOP! strengthening when it is not appropriate. The way I often explain this to patients or students is to pretend that a patient has walked in to the clinic with the shoulders elevated maximally, complaining of headaches or shoulder dysfunction. Then I say, "Great! Let's hit the weights- you just need to strengthen your upper traps." This always gets a giggle or a smirk, but the point is this: that is exactly what providers are doing to patients who walk in with bowel, bladder, pain, or sexual dysfunction when the announcement is made that "you just need to do your Kegels." 

 

While we do not want to villainize Kegels or strengthening of the pelvic muscles, we do want our colleagues, our patients, and the valued referring providers to know that there is way more to pelvic health than strengthening. The abundance of bad advice available to our patients may leave them in worse condition and with less hope about finding relief. While well-intentioned, advice that only describes strengthening as the cure is misleading and potentially harmful.

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Endometriosis and adolescence

Recent research in The Journal of Pediatric and Adolescent Gynecology points to the alarming number of young women who present with pelvic pain who in fact also have endometriosis. Dr. Opoku-Anane and Dr. Laufer report that prevalence rates of endometriosis in an adolescent gynecology population have likely been underestimated (reported range of 25-47%) and that with advanced surgical methods the rates have been estimated to be as high as 73% in those who have pelvic pain. In their retrospective study, 117 subjects ages 12-21 completed laparoscopic examination for endometriosis. These subjects did not previously respond to non-steroidal anti-inflammatories or to oral contraceptives, and they were all referred for evaluation of chronic pelvic pain. In addition to collecting data about patient symptoms, the stage and descriptions of any endometrial lesions were documented.

A remarkable 115 of the 117 subjects (98%) presented with Stage I or II endometriosis as defined by the American Society for Reproductive Medicine guidelines. (Click here for the link to a detailed patient education document from the ASRM that describes endometriosis as well as staging.) The median age for onset of menarche in this population was 12 years old, and the median age of first symptoms reported occurred at age 13. Nearly 16% of the subjects also reported gastrointestinal complaints, menstrual irregularity in nearly 8%, and 76% of the participants reported a family history that included endometriosis, severe dysmenorrhea, and/or infertility. The authors of this research point out that advances made in surgical technique, both from a technological standpoint and a physician skill level, may be contributing factors in the increased rates of diagnosis of endometriosis.The authors also point out that it is yet unknown if early diagnosis and treatment will lead to improved outcomes in this population.

If you are interested in learning more about endometriosis in general, click here to follow the link to a free, full text article in PubMed Central. The article was first published in 2008, and even though advances in surgical diagnosis have been made, most of the information related to symptoms, medical treatment, and related risks remain significantly unchanged. In relation to etiology of endometriosis, one study that has set forth an environmental risk for endometriosis can be accessed here. Dr. C. Matthew Peterson, one of the researchers involved with the ENDO study, presented at the 2011 International Pelvic Pain Society meeting, and he encouraged all present to consider implementing strategies to minimize risks from chemicals in our daily lives. The Environmental Protection Agency offers advice towards protecting our health that can be accessed here. If environmental hazards are influencing the onset or progression of conditions such as endometriosis, it is in our best interest to reduce these risks. Consider not only the product exposure at home, but also at the workplace, and request less toxic products including cleaners when able.

In relation to pelvic rehabilitation, patients who present with pelvic pain or other pelvic health issues due to endometriosis often find relief when working with pelvic rehab providers. While surgery may be critical in reducing severe adhesions, maximizing tissue health and patient mobility and function is a job in which we can all actively participate. The evaluation and treatment of pelvic pain is instructed at various levels of depth in all of the main series courses as well as in many other courses offered at the Herman & Wallace Pelvic Rehabilitation Institute.

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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Chicago, IL (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Cancer Treatment Centers of America - Chicago, IL

Male Pelvic Floor - St. Paul, MN (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Regions Hospital

Pelvic Floor Level 1 - Boston, MA (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Marathon Physical Therapy

Chronic Pelvic Pain - Kansas City, MO (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Saint Luke\'s Health System

Pudendal Neuralgia and Nerve Entrapment - Philadelphia, PA (Rescheduled)

Apr 4, 2020 - Apr 5, 2020
Location: Core 3 Physical Therapy

Pelvic Floor Level 2B - Freehold, NJ (Rescheduled)

Apr 4, 2020 - Apr 6, 2020
Location: CentraState Medical Center

Sexual Interviewing for Pelvic Health Therapists - Seattle, WA (Rescheduled)

Apr 4, 2020 - Apr 5, 2020
Location: Evergreen Hospital Medical Center

Pelvic Floor Level 2A - Grand Rapids, MI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Mary Free Bed Rehabilitation Hospital

Pelvic Floor Level 1- Kansas City, MO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Centerpoint Medical Center

Oncology of the Pelvic Floor Level 1 - Grand Junction, CO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Urological Associates of Western Colorado

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Virginia Hospital Center

Pelvic Floor Level 2B - East Greenwich, RI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: New England Institute of Technology

Pilates for the Pelvic Floor - Livingston, NJ (Rescheduled)

Apr 18, 2020 - Apr 19, 2020
Location: Ambulatory Care Center- RWJ Barnabas Health

Genital Lymphedema

Apr 24, 2020

Pelvic Floor Level 1- Canton, OH (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Aultman Hospital

Pelvic Floor Level 1 - Rochester, NY (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Unity Health System

Pediatric Functional Gastrointestinal Disorders - Ann Arbor, MI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Michigan Medicine

Lumbar Nerve Manual Assessment and Treatment - Madison, WI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: University of Wisconsin Hospital

Pelvic Floor Level 2A - Winfield, IL (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Northwestern Medicine

Low Pressure Fitness for Pelvic Floor Care - Trenton, NJ (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Robert Wood Johnson Medical Associates

Athletes & Pelvic Rehabilitation - Minneapolis, MN (Rescheduled)

Apr 25, 2020 - Apr 26, 2020
Location: Viverant

Sacral Nerve Manual Assessment and Treatment - Fairlawn, NJ

May 1, 2020 - May 3, 2020
Location: Bella Physical Therapy

Pelvic Floor Level 1 - Fayetteville, AR

May 1, 2020 - May 3, 2020
Location: Washington Regional Medical Center

Pelvic Floor Level 1 - Boise, ID

May 1, 2020 - May 3, 2020
Location: St Luke's Rehab Hospital

Pediatric Incontinence - Duluth, MN

May 1, 2020 - May 3, 2020
Location: Polinsky Medical Rehabilitation Center

Yoga for Pelvic Pain - Online Course

May 2, 2020 - May 3, 2020